AAA North Penn
Reimbursement request form
Member name: ______________________________ Membership # ________________________
Home Address: _____________________________ Telephone # ___________________________
City: ______________________________________State: ______Zip Code: ___________________
Date of service: ______/______/______
Exact location of breakdown:
__________________________________________
(Please indicate highway number, road name, and street address if known)
Name of business providing service ___________________________________________________
Year, make and model of vehicle: Yr.________Make:_______________ Model: _______________
If towed, where? _____________________________________________ Miles towed: _________
Amount requested $___________ (original paid itemized receipt must be attached)
Was AAA called? Yes _____ No ____
Is this reimbursement for accident related charges? Yes_____ No____ If yes, please attach
police report.
(
Police report will be needed to honor any requests for reimbursement due to an accident)
Was a valid AAA membership card presented at time of service? Yes______ No ______
If Non-AAA Emergency road service was utilized, please explain why: ____________________
______________________________________________________________________________
______________________________________________________________________________
Service provided: Tow___ Jump start _____ Tire ____ Lockout ____ Fuel ____ Winch _______
Remarks ______________________________________________________________________
_______________________________________________________________________________
For office use only: Basic $_______Plus $_________Total $ ______T - code: ______
Mailing address:
AAA North Penn
1125 N Washington Ave
Scranton, PA 18509
Attn: ERS